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Background and purpose: In the BOOG 2013-08 trial (NCT02271828), cT1-2N0 breast cancer patients were randomized between breast conserving surgery with or without sentinel lymph node biopsy (SLNB) followed by whole breast radiotherapy (WBRT). While awaiting primary endpoint results (axillary recurrence rate), this study aims to perform a quality assurance analysis on protocol adherence and (incidental) axillary radiation therapy (RT) dose. Materials and methods: Patients were enrolled between 2015 and 2022. Data on prescribed RT and (in 25% of included patients) planning target volumes (PTV) parameters were recorded for axillary levels I-IV and compared between treatment arms. Multivariable linear regression analysis was performed to determine prognostic variables for incidental axillary RT dose. Results: 1,439/1,461 included patients (98.5%) were treated according to protocol and 87 patients (5.9%) received regional RT (SLNB 10.9%, no-SLNB 1.5 %). In 326 patients included in the subgroup analysis, the mean incidental PTV dose at axilla level I was 59.5% of the prescribed breast RT dose. In 5 patients (1.5%) the mean PTV dose at level I was ≥95% of the prescribed breast dose. No statistically or clinically significant differences regarding incidental axillary RT dose were found between treatment arms. Tumour bed boost (yes/no) was associated with a higher incidental mean dose in level I (R2 = 0.035, F(6, 263) = 1.532, p 0.168). Conclusion: The results indicate that RT-protocol adherence was high, and that incidental axillary RT dose was low in the BOOG 2013-08 trial. Potential differences between treatmentarms regarding the primary endpoint can thus not be attributed to different axillary radiation doses.

Objective: Stillbirth is a potentially preventable complication of pregnancy. Identifying women at high risk of stillbirth can guide decisions on the need for closer surveillance and timing of delivery in order to prevent fetal death. Prognostic models have been developed to predict the risk of stillbirth, but none has yet been validated externally. In this study, we externally validated published prediction models for stillbirth using individual participant data (IPD) meta-analysis to assess their predictive performance. Methods: MEDLINE, EMBASE, DH-DATA and AMED databases were searched from inception to December 2020 to identify studies reporting stillbirth prediction models. Studies that developed or updated prediction models for stillbirth for use at any time during pregnancy were included. IPD from cohorts within the International Prediction of Pregnancy Complications (IPPIC) Network were used to validate externally the identified prediction models whose individual variables were available in the IPD. The risk of bias of the models and cohorts was assessed using the Prediction study Risk Of Bias ASsessment Tool (PROBAST). The discriminative performance of the models was evaluated using the C-statistic, and calibration was assessed using calibration plots, calibration slope and calibration-in-the-large. Performance measures were estimated separately in each cohort, as well as summarized across cohorts using random-effects meta-analysis. Clinical utility was assessed using net benefit. Results: Seventeen studies reporting the development of 40 prognostic models for stillbirth were identified. None of the models had been previously validated externally, and the full model equation was reported for only one-fifth (20%, 8/40) of the models. External validation was possible for three of these models, using IPD from 19 cohorts (491 201 pregnant women) within the IPPIC Network database. Based on evaluation of the model development studies, all three models had an overa

Fusarium mycotoxins are inactivated by rumen flora; however, a certain amount can pass the rumen and reticulum or be converted into biological active metabolites. Limited scientific evidence is available on the impact and mitigation of Fusarium mycotoxins on dairy cows’ performance and health, particularly when cows are exposed for an extended period (more than 2 months). The available information related to these mycotoxin effects on milk cheese-making parameters is also very poor. The objective of this study was to evaluate a commercially available mycotoxin mitigation product (MMP, i.e., TOXO® HP-R, Selko, Tilburg, The Netherlands) in lactating dairy cows fed a Fusarium mycotoxin-contaminated diet, and the repercussions on the dry matter intake, milk yield, milk quality, cheese-making traits and health status of cows. The MMP contains smectite clays, yeast cell walls and antioxidants. In the study, 36 lactating Holstein cows were grouped based on the number of days of producing milk, milk yield, body condition score and those randomly assigned to specific treatments. The study ran over 2 periods (March/May–May/July 2022). In each period, six animals/treatment were considered. The experimental periods consisted of 9 days of adaptation and 54 days of exposure. The physical activity, rumination time, daily milk production and milk quality were measured. The cows were fed once daily with the same total mixed ration (TMR) composition. The experimental groups consisted of a control (CTR) diet, with a TMR with low contamination, high moisture corn (HMC), and beet pulp; a mycotoxins (MTX) diet, with a TMR with highly contaminated HMC, and beet pulp; and an MTX diet supplemented with 100 g/cow/day of the mycotoxin mitigation product (MMP). The trial has shown that the use of MMP reduced the mycotoxin’s negative effects on the milk yield and quality (protein, casein and lactose). The MTX diet had a lower milk yield and feed efficiency than the CTR and MMP HP-R diets. The M

Background: An economic evaluation was performed alongside an RCT investigating flap fixation in reducing seroma formation after mastectomy. The evaluation focused on the first year following mastectomy and assessed cost-effectiveness from a health care and societal perspective. Methods: The economic evaluation was conducted between 2014 and 2018 in four Dutch breast clinics. Patients with an indication for mastectomy or modified radical mastectomy were randomly assigned to: conventional closure (CON), flap fixation with sutures (FFS) or flap fixation with tissue glue (FFG). Health care costs, patient and family costs and costs due to productivity losses were assessed. Outcomes were expressed in incremental cost-effectiveness ratios (ICERs): the incremental cost per quality-adjusted life year (QALY). Bootstrapping techniques, sensitivity and secondary analyses were employed to address uncertainty. Results: The FFS-group yielded most QALYs (0.810; 95%-CI 0.755–0.856), but also incurred the highest mean costs at twelve months (€10.416; 95%-CI 8.231–12.930). CON was the next best alternative with 0.794 QALYs (95%-CI 0.733–0.841) and mean annual costs of €10.051 (95%-CI 8.255–12.044). FFG incurred fewer QALYs and higher costs, when compared to the CON group. The ICER of FFS compared to CON was €22.813/QALY. Applying a willingness to pay threshold in the Netherlands of €20.000/QALY, the probability that FFS was cost-effective was 42%, compared to 37% and 21% for CON and FFG, respectively. Conclusion: The cost-effectiveness of FFS following mastectomy, versus CON and FFG, is uncertain from a societal perspective. Yet, from a health care and hospital perspective FFS is likely to be the most cost-effective intervention.

Objective: To develop a prediction model for the development of hypertension in the decade following pre-eclampsia in women who were normotensive shortly after pregnancy. Methods: This was a longitudinal cohort study of formerly pre-eclamptic women attending a university hospital in The Netherlands between 1996 and 2019. We developed a prediction model for incident hypertension using multivariable logistic regression analysis. The model was validated internally using bootstrapping techniques. Results: Of 259 women, 185 (71%) were normotensive at the first cardiovascular assessment, at a median of 10 (interquartile range (IQR), 6–24) months after a pre-eclamptic pregnancy, of whom 49 (26%) had developed hypertension by the second visit, at a median of 11 (IQR, 6–14) years postpartum. The prediction model, based on birth-weight centile, mean arterial pressure, total cholesterol, left ventricular mass index and left ventricular ejection fraction, had good-to-excellent discriminative ability, with an area under the receiver-operating-characteristics curve (AUC) of 0.82 (95% CI, 0.75–0.89) and an optimism-corrected AUC of 0.80. The sensitivity and specificity of our model to predict hypertension were 98% and 34%, respectively, and positive and negative predictive values were 35% and 98%, respectively. Conclusions: Based on five variables, we developed a good-to-excellent predictive tool to identify incident hypertension following pre-eclampsia in women who were normotensive shortly after pregnancy. After external validation, this model could have considerable clinical utility in tackling the cardiovascular legacy of pre-eclampsia.

Introduction: There is an increase in use of extracorporeal life support (ECLS) for cardiac support, with new indications emerging. Bleeding complications are the most frequent complications, associated with high morbidity and mortality. Despite the high frequency, the risk factors for bleeding complications remain poorly investigated. Method(s): To develop a prediction model for bleeding complications, adult patients included in the Extracorporeal Life Support Organization (ELSO) registry undergoing V-A ECLS between 2000 and 2020 were analyzed. The primary outcome was bleeding complications during V-A ECLS. Backward stepwise elimination in multivariable logistic regression analysis was used to develop the prediction model. The performance of the model was tested by ROC curves with AUC for discriminative ability and calibration plots. To detect overfitting of the model, internal validation was performed. Result(s): Single V-A ECLS runs were recorded in 28.767 adult patients, of which 29,0% developed bleeding complications. Sex, BMI, surgical cannulation, respiratory and hemodynamic variables prior to ECLS, the use of additional support devices, pre-ECLS interventions and different type of diagnosis were included in the prediction model. The model showed a fair predictive capability with an AUC of 0.66. Internal validation showed almost no overfitting of the model. An online calculator may simplify the use of the model. Conclusion(s): A multivariable model was developed and internally validated to calculate the risk for bleeding complications for adult patients receiving V-A ECLS. This model showed a favorabel predictive capability compared to the current literature. External validation is needed to confirm clinical use of this model.

Introduction: There is an increase in use of extracorporeal life support (ECLS) for cardiac support, with new indications emerging. Bleeding complications are the most frequent complications, associated with high morbidity and mortality. Despite the high frequency, the risk factors for bleeding complications remain poorly investigated. Method(s): To develop a prediction model for bleeding complications, adult patients included in the Extracorporeal Life Support Organization (ELSO) registry undergoing V-A ECLS between 2000 and 2020 were analyzed. The primary outcome was bleeding complications during V-A ECLS. Backward stepwise elimination in multivariable logistic regression analysis was used to develop the prediction model. The performance of the model was tested by ROC curves with AUC for discriminative ability and calibration plots. To detect overfitting of the model, internal validation was performed. Result(s): Single V-A ECLS runs were recorded in 28.767 adult patients, of which 29,0% developed bleeding complications. Sex, BMI, surgical cannulation, respiratory and hemodynamic variables prior to ECLS, the use of additional support devices, pre-ECLS interventions and different type of diagnosis were included in the prediction model. The model showed a fair predictive capability with an AUC of 0.66. Internal validation showed almost no overfitting of the model. An online calculator may simplify the use of the model. Conclusion(s): A multivariable model was developed and internally validated to calculate the risk for bleeding complications for adult patients receiving V-A ECLS. This model showed a favorabel predictive capability compared to the current literature. External validation is needed to confirm clinical use of this model.

Background: Seroma is a common complication after mastectomy. The aim of this review is to elucidate whether closed suction drainage can safely be omitted in patients undergoing mastectomy when assessing seroma formation and its complications. The second aim is to assess the influence of flap fixation on seroma related complications, as there is existing evidence showing that combining mastectomy with flap fixation may make the use of drainage systems obsolete.Search & selection: A review of the literature was performed and articles that compared mastectomy with drainage and mastectomy without drainage were selected. Due to the small number of eligible studies, no selection based on whether flap fixation was performed was possible. If outcome was described in terms of seroma formation or seroma related complications, papers were eligible for inclusion. Studies older than 20 years, animal studies, studies not written in English and studies with male patients were excluded.Results: A total of eight articles were eligible for inclusion. Four prospective studies and four retrospective studies were included. In four studies, flap fixation was performed. Frequency of seroma formation as well as seroma that required intervention was reported. The included studies demonstrated that omitting closed suction drainage does not lead to a higher incidence of seroma formation in patients undergoing mastectomy.Conclusion: Despite substantial heterogeneity, there is evidence that drainage can safely be omitted without exacerbating seroma formation and its complications. A well-powered, randomized controlled trial evaluating the effect of drainage omission on seroma formation, with or without flap fixation, is needed. (C) 2020 Elsevier Ltd, BASO similar to The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

Background Seroma is a common complication after mastectomy, with an incidence of 3% to 85%. Seroma is associated with pain, delayed wound healing, and additional outpatient clinic visits, leading potentially to repeated seroma aspiration or even surgical interventions. This study aimed to assess the effect of flap fixation using sutures or tissue glue in preventing seroma formation and its sequelae. Methods Between June 2014 and July 2018, 339 patients with an indication for mastectomy or modified radical mastectomy were enrolled in this randomized controlled trial in the Netherlands. Patients were randomly allocated to one of the three following arms: conventional wound closure (CON,n = 115), flap fixation using sutures (FFS,n = 111) or flap fixation using tissue glue (FFG,n = 113). The primary outcome was the need for seroma aspiration. The secondary outcomes were additional outpatient department visits, surgical-site infection, shoulder function and mobility, cosmesis, skin-dimpling, and postoperative pain scores. Results Flap fixation after mastectomy leads to fewer seroma aspirations than conventional wound closure (CON 17.5% vs FFS 7.3% vs FFG 10.8%;p = 0.057), with a significant difference between flap fixation with sutures and conventional wound closure (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.16-0.89;p = 0.025). Flap fixation has no significant negative effect on surgical-site infections, shoulder function and mobility, cosmesis, skin-dimpling, or postoperative pain. Conclusion Flap fixation using sutures leads to a significant reduction in aspirations of post-mastectomy seromas. The authors strongly advise surgeons to use sutures for flap fixation in patients undergoing mastectomy. (ClinicalTrials.gov no. NCT03305757). Preregistration The trial was registered after enrollment of the first participant. However, no specific explanation exists for this except that through the years more importance has been given to central trial registratio

Background: Seroma is a common complication after mastectomy. The aim of this review is to elucidate whether closed suction drainage can safely be omitted in patients undergoing mastectomy when assessing seroma formation and its complications. The second aim is to assess the influence of flap fixation on seroma related complications, as there is existing evidence showing that combining mastectomy with flap fixation may make the use of drainage systems obsolete.Search & selection: A review of the literature was performed and articles that compared mastectomy with drainage and mastectomy without drainage were selected. Due to the small number of eligible studies, no selection based on whether flap fixation was performed was possible. If outcome was described in terms of seroma formation or seroma related complications, papers were eligible for inclusion. Studies older than 20 years, animal studies, studies not written in English and studies with male patients were excluded.Results: A total of eight articles were eligible for inclusion. Four prospective studies and four retrospective studies were included. In four studies, flap fixation was performed. Frequency of seroma formation as well as seroma that required intervention was reported. The included studies demonstrated that omitting closed suction drainage does not lead to a higher incidence of seroma formation in patients undergoing mastectomy.Conclusion: Despite substantial heterogeneity, there is evidence that drainage can safely be omitted without exacerbating seroma formation and its complications. A well-powered, randomized controlled trial evaluating the effect of drainage omission on seroma formation, with or without flap fixation, is needed. (C) 2020 Elsevier Ltd, BASO similar to The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

Background Seroma is a common complication after mastectomy, with an incidence of 3% to 85%. Seroma is associated with pain, delayed wound healing, and additional outpatient clinic visits, leading potentially to repeated seroma aspiration or even surgical interventions. This study aimed to assess the effect of flap fixation using sutures or tissue glue in preventing seroma formation and its sequelae. Methods Between June 2014 and July 2018, 339 patients with an indication for mastectomy or modified radical mastectomy were enrolled in this randomized controlled trial in the Netherlands. Patients were randomly allocated to one of the three following arms: conventional wound closure (CON,n = 115), flap fixation using sutures (FFS,n = 111) or flap fixation using tissue glue (FFG,n = 113). The primary outcome was the need for seroma aspiration. The secondary outcomes were additional outpatient department visits, surgical-site infection, shoulder function and mobility, cosmesis, skin-dimpling, and postoperative pain scores. Results Flap fixation after mastectomy leads to fewer seroma aspirations than conventional wound closure (CON 17.5% vs FFS 7.3% vs FFG 10.8%;p = 0.057), with a significant difference between flap fixation with sutures and conventional wound closure (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.16-0.89;p = 0.025). Flap fixation has no significant negative effect on surgical-site infections, shoulder function and mobility, cosmesis, skin-dimpling, or postoperative pain. Conclusion Flap fixation using sutures leads to a significant reduction in aspirations of post-mastectomy seromas. The authors strongly advise surgeons to use sutures for flap fixation in patients undergoing mastectomy. (ClinicalTrials.gov no. NCT03305757). Preregistration The trial was registered after enrollment of the first participant. However, no specific explanation exists for this except that through the years more importance has been given to central trial registratio

Identifying determinants of long-term functional outcome after a distal radius fracture is challenging. Previously, we reported on the association between early HR-pQCT measurements and clinical outcome 12 weeks after a conservatively treated distal radius fracture. We extended the follow-up and assessed functional outcome after two years in relation to early HR-pQCT derived bone parameters.HR-pQCT scans of the fracture region were performed in 15 postmenopausal women with a distal radius fracture at 1-2 (baseline), 3-4 weeks and 26 months post-fracture. Additionally, the contralateral distal radius was scanned at baseline. Bone density, micro-architecture parameters and bone stiffness using micro-finite element analysis (FEA) were evaluated. During all visits, wrist pain and function were assessed using the patient-rated wrist evaluation questionnaire (PRWE), quantifying functional outcome with a score between 0 and 100.Two-year PRWE was associated with torsional and bending stiffness 3-4 weeks post-fracture (R-2: 0.49, p = 0.006 and R-2: 0.54, p = 0.003, respectively). In contrast, early micro-architecture parameters of the fracture region or contralateral bone parameters did not show any association with long-term outcome.This exploratory study indicates that HR-pQCT with mu FEA performed within four weeks after a distal radius fracture captures biomechanical fracture characteristics that are associated with long-term functional outcome and therefore could be a valuable early outcome measure in clinical trials and clinical practice.

Objective To evaluate the association between different pre-eclampsia (PE) phenotypes and the development of metabolic syndrome postpartum, in order to identify the subgroup of formerly pre-eclamptic women with a worse cardiovascular risk profile requiring tailored postpartum follow-up. Methods This was a cohort study of 1102 formerly pre-eclamptic women in whom cardiovascular and cardiometabolic evaluation was performed at least 3 months postpartum. Women were divided into four subgroups based on PE resulting in delivery before 34 weeks (early-onset (EO)) or at or after 34 weeks (late onset (LO)) of gestation and whether they delivered a small-for-gestational-age (SGA) neonate. Metabolic syndrome was diagnosed as the presence of hyperinsulinemia along with two or more of: body mass index >= 30 kg/m(2); dyslipidemia; hypertension; and microalbuminuria or proteinuria. Data were compared between groups using ANOVA after Bonferroni correction. Odds ratios (OR) were calculated using logistic regression to determine the association between metabolic syndrome and the four subgroups. We constructed receiver-operating characteristics curves and computed the area under the curve (AUC) to quantify the ability of different obstetric variables to distinguish between women who developed metabolic syndrome and those who did not. Results The prevalence of metabolic syndrome was higher in women with EO-PE and SGA (25.8%) than in those with EO-PE without SGA (14.7%) (OR 2.01 (95% CI, 1.34-3.03)) and approximately five-fold higher than in women with LO-PE with SGA (5.6%) (OR 5.85 (95% CI, 2.60-13.10)). In women with LO-PE, the prevalence of metabolic syndrome did not differ significantly between women with and those without SGA. Multivariate analysis revealed that a history of SGA, a history of EO-PE and systolic blood pressure at the time of screening are the best predictors of developing metabolic syndrome postpartum. The AUC of the model combining these three variables was 7

Identifying determinants of long-term functional outcome after a distal radius fracture is challenging. Previously, we reported on the association between early HR-pQCT measurements and clinical outcome 12 weeks after a conservatively treated distal radius fracture. We extended the follow-up and assessed functional outcome after two years in relation to early HR-pQCT derived bone parameters.HR-pQCT scans of the fracture region were performed in 15 postmenopausal women with a distal radius fracture at 1-2 (baseline), 3-4 weeks and 26 months post-fracture. Additionally, the contralateral distal radius was scanned at baseline. Bone density, micro-architecture parameters and bone stiffness using micro-finite element analysis (FEA) were evaluated. During all visits, wrist pain and function were assessed using the patient-rated wrist evaluation questionnaire (PRWE), quantifying functional outcome with a score between 0 and 100.Two-year PRWE was associated with torsional and bending stiffness 3-4 weeks post-fracture (R-2: 0.49, p = 0.006 and R-2: 0.54, p = 0.003, respectively). In contrast, early micro-architecture parameters of the fracture region or contralateral bone parameters did not show any association with long-term outcome.This exploratory study indicates that HR-pQCT with mu FEA performed within four weeks after a distal radius fracture captures biomechanical fracture characteristics that are associated with long-term functional outcome and therefore could be a valuable early outcome measure in clinical trials and clinical practice.

Objective To evaluate the association between different pre-eclampsia (PE) phenotypes and the development of metabolic syndrome postpartum, in order to identify the subgroup of formerly pre-eclamptic women with a worse cardiovascular risk profile requiring tailored postpartum follow-up. Methods This was a cohort study of 1102 formerly pre-eclamptic women in whom cardiovascular and cardiometabolic evaluation was performed at least 3 months postpartum. Women were divided into four subgroups based on PE resulting in delivery before 34 weeks (early-onset (EO)) or at or after 34 weeks (late onset (LO)) of gestation and whether they delivered a small-for-gestational-age (SGA) neonate. Metabolic syndrome was diagnosed as the presence of hyperinsulinemia along with two or more of: body mass index >= 30 kg/m(2); dyslipidemia; hypertension; and microalbuminuria or proteinuria. Data were compared between groups using ANOVA after Bonferroni correction. Odds ratios (OR) were calculated using logistic regression to determine the association between metabolic syndrome and the four subgroups. We constructed receiver-operating characteristics curves and computed the area under the curve (AUC) to quantify the ability of different obstetric variables to distinguish between women who developed metabolic syndrome and those who did not. Results The prevalence of metabolic syndrome was higher in women with EO-PE and SGA (25.8%) than in those with EO-PE without SGA (14.7%) (OR 2.01 (95% CI, 1.34-3.03)) and approximately five-fold higher than in women with LO-PE with SGA (5.6%) (OR 5.85 (95% CI, 2.60-13.10)). In women with LO-PE, the prevalence of metabolic syndrome did not differ significantly between women with and those without SGA. Multivariate analysis revealed that a history of SGA, a history of EO-PE and systolic blood pressure at the time of screening are the best predictors of developing metabolic syndrome postpartum. The AUC of the model combining these three variables was 7

Purpose: DW-MRI parameters such as ADC hold the potential for more reliable staging of cervical cancer. We compared 2D region of interest (ROI) measurement techniques to 3D tumor analysis in the evaluation of ADC for cervical cancer. Secondly, we evaluated the utility of ADC for assessing parametrial and/or lymph node involvement.Method: This prospective patient cohort registered cervical cancer patients who underwent pre-operative MRI with T1, T2W, and axial DWI. Retrospectively, two observers independently and blindly scored mean, minimum, and maximum ADC using three methods: a) 3D-Tumor analysis, b) single freehand ROI (2D-Slice), and c) single circular ROI (2D-Circle). Another observer scored parametrial and lymph node involvement on T1/T2W sequences. Parametrial and/or lymph node involvement were determined by surgical-pathologic results. The diagnostic performance of ADC for predicting the latter was evaluated by ROC curve, uni and multivariate analyses.Results: Of 58 included patients, parametrial and/or lymph node involvement was found in 9 and 11 patients, respectively. Mean ADC (ADC(Mean)) was least dependent on ROI technique, with interobserver variability (ICC: 0.88-0.90) and linear correlation (Pearson's r: 0.95-0.96). To the contrary, minimal and maximal ADC were significantly influenced by 2D-ROI techniques. ADC(mean) was shown to be an independent predictor of parametrial (AUC: 0.80-0.86; OR: 16, 1.4-178) and/or lymph node involvement (AUC: 0.74-0.79; OR: 5.1, 1.1-24).Conclusions: Single ROI measurements are a reliable method for determining ADC(Mean) in cervical cancer. Second, ADC(Mean) serves as a potential parameter for prediction of parametrial involvement prior to radical hysterectomy.

Purpose The aim of the study was to assess the long-term outcome of a Malone antegrade continence enema (MACE) procedure for fecal incontinence or constipation in adults. Methods This retrospective single-center study assessed the long-term outcome and quality of life (QoL) of patients who underwent a MACE procedure between 2005 and 2014 at the Maastricht University Medical Centre. Success rate was quantified by using Malone's continence scale. Quality of life was assessed by validated questionnaires covering general quality of life (SF-36 and Karnofsky scale), current pain level (visual analog scale), fecal incontinence (Vaizey incontinence survey), or constipation (Cleveland Clinic Constipation Score). Results Based on patients' records, 22 out of 30 patients (73%; 95% CI 54-87%) were still using their MACE. Mean follow-up was 43 months (SD 25.9) since time of surgery. According to the Malone continence scale, the overall success rate was 37% (95% CI 20.0-53.3). Nine patients developed a postoperative complication. Eighteen out of 22 patients (13 with constipation and 5 with fecal incontinence) returned the QoL questionnaires (82% response rate). Long-term quality of life of patients with a MACE did not differ from the general Dutch population. Conclusions In our cohort of patients with fecal incontinence or constipation, MACE resulted in a disappointed overall success rate of 37%. However, it may be indicated in patients who do not prefer more invasive surgical procedures or a definite stoma. The success and morbidity rate should be thoroughly discussed with the patients preoperatively.

Purpose The aim of the study was to assess the long-term outcome of a Malone antegrade continence enema (MACE) procedure for fecal incontinence or constipation in adults. Methods This retrospective single-center study assessed the long-term outcome and quality of life (QoL) of patients who underwent a MACE procedure between 2005 and 2014 at the Maastricht University Medical Centre. Success rate was quantified by using Malone's continence scale. Quality of life was assessed by validated questionnaires covering general quality of life (SF-36 and Karnofsky scale), current pain level (visual analog scale), fecal incontinence (Vaizey incontinence survey), or constipation (Cleveland Clinic Constipation Score). Results Based on patients' records, 22 out of 30 patients (73%; 95% CI 54-87%) were still using their MACE. Mean follow-up was 43 months (SD 25.9) since time of surgery. According to the Malone continence scale, the overall success rate was 37% (95% CI 20.0-53.3). Nine patients developed a postoperative complication. Eighteen out of 22 patients (13 with constipation and 5 with fecal incontinence) returned the QoL questionnaires (82% response rate). Long-term quality of life of patients with a MACE did not differ from the general Dutch population. Conclusions In our cohort of patients with fecal incontinence or constipation, MACE resulted in a disappointed overall success rate of 37%. However, it may be indicated in patients who do not prefer more invasive surgical procedures or a definite stoma. The success and morbidity rate should be thoroughly discussed with the patients preoperatively.

Gaining sufficient knowledge of anatomy is an important part of medical education. Factors that influence how well students learn anatomical structures include available sources, learning time and study assistance. This study explores the attitude of medical students with regard to studying anatomy and evaluates possibilities for improvement of training in anatomy. Twenty medical students participated in a focus group meeting. Based on this focus group, an online survey consisting of 27 questions was developed and distributed amongst medical students of Maastricht University, the Netherlands. A total of 495 medical students (both Bachelor and Master level) participated in this survey. Master students found studying anatomy less attractive than Bachelor students (36.8% of the Master students vs. 47.9% of the Bachelor students (p = .024)). Although most students responded that they thought it is important to study anatomy, 48% of all students studied anatomy less than 10 h per study block of 8 weeks. Only 47.9% of the students rated their knowledge of anatomy as adequate. Students suggested that three-dimensional techniques would help improve their knowledge of anatomy. Therefore investing in three-dimensional tools could prove beneficial in the future. (C) 2018 Elsevier GmbH. All rights reserved.

In this master thesis the reader will find the application of a hybrid forensic investigation on a CubeSat project. This CubeSat, known as Delfi-n3Xt, was developed by the Delft University of Technology and it was launched in November 2013. The satellite was successfully operated for three months but contact was lost after execution of an experiment. The reader will find that the investigation is greatly affected by a lack of facts. There is no accessible physical evidence, the CubeSat wasn’t formally verified, and internal documents are lacking in many aspects. Therefore, the research methodology itself is the topic of interest and Delfi-n3Xt is used as a case-study. Due to the lack of facts, a combination of a forensic approach and a more general empirical approach is used. In this thesis, the satellite operations are reviewed extensively by inspection of orbital elements, by an extensive telemetry analysis, by a reconstruction of the mission and by a detailed analysis of the last moments of contact. Beyond the operations, the design of the ISIS Transceiver (ITRX), including the Linear Transponder (LT), is reviewed to identify hypotheses. During this thesis over 30 hypotheses were identified. Some hypotheses are directly related to the loss of contact and some are not. Since many hypotheses were identified, a selection was made for verification. This selection procedure was based on a methodology similar to a risk assessment, where the hypotheses with highest risk are selected. Eventually five verification campaigns were performed. One campaign was based on analysis and the other four were based on tests using spare hardware. Unfortunately, no root cause was found during this thesis, but two hypotheses were rejected, one hypothesis was verified, and one hypothesis was considered plausible and highly likely. Based on the achieved results it is concluded that the used methodology is effective for cases like Delfi-n3Xt, were evidence is lacking. It is acknowledged ho, Aerospace Engineering, Space Systems Engineering

In this master thesis the reader will find the application of a hybrid forensic investigation on a CubeSat project. This CubeSat, known as Delfi-n3Xt, was developed by the Delft University of Technology and it was launched in November 2013. The satellite was successfully operated for three months but contact was lost after execution of an experiment. The reader will find that the investigation is greatly affected by a lack of facts. There is no accessible physical evidence, the CubeSat wasn’t formally verified, and internal documents are lacking in many aspects. Therefore, the research methodology itself is the topic of interest and Delfi-n3Xt is used as a case-study. Due to the lack of facts, a combination of a forensic approach and a more general empirical approach is used. In this thesis, the satellite operations are reviewed extensively by inspection of orbital elements, by an extensive telemetry analysis, by a reconstruction of the mission and by a detailed analysis of the last moments of contact. Beyond the operations, the design of the ISIS Transceiver (ITRX), including the Linear Transponder (LT), is reviewed to identify hypotheses. During this thesis over 30 hypotheses were identified. Some hypotheses are directly related to the loss of contact and some are not. Since many hypotheses were identified, a selection was made for verification. This selection procedure was based on a methodology similar to a risk assessment, where the hypotheses with highest risk are selected. Eventually five verification campaigns were performed. One campaign was based on analysis and the other four were based on tests using spare hardware. Unfortunately, no root cause was found during this thesis, but two hypotheses were rejected, one hypothesis was verified, and one hypothesis was considered plausible and highly likely. Based on the achieved results it is concluded that the used methodology is effective for cases like Delfi-n3Xt, were evidence is lacking. It is acknowledged ho, Aerospace Engineering, Space Systems Engineering

Background There is an ongoing discussion on the rising CS rate worldwide. Suboptimal guideline adherence may be an important contributor to this rise. Before improvement of care can be established, optimal CS care in different settings has to be defined. This study aimed to develop and measure quality indicators to determine guideline adherence and identify target groups for improvement of care with direct effect on caesarean section (CS) rates. Method Eighteen obstetricians and midwives participated in an expert panel for systematic CS quality indicator development according to the RAND-modified Delphi method. A multi-center study was performed and medical charts of 1024 women with a CS and a stratified and weighted randomly selected group of 1036 women with a vaginal delivery were analysed. Quality indicator frequency and adherence were scored in 2060 women with a CS or vaginal delivery. Results The expert panel developed 16 indicators on planned CS and 11 indicators on unplanned CS. Indicator adherence was calculated, defined as the number of women in a specific obstetrical situation in which care was performed as recommended in both planned and unplanned CS settings. The most frequently occurring obstetrical situations with low indicator adherence were: 1) suspected fetal distress (frequency 17%, adherence 46%), 2) nonprogressive labour (frequency 12%, CS performed too early in over 75%), 3) continuous support during labour (frequency 88%, adherence 37%) and 4) previous CS (frequency 12%), with adequate counselling in 15%. Conclusions We identified four concrete target groups for improvement of obstetrical care, which can be used as a starting point to reduce CS rates worldwide.